Trying to understand how physical therapy is covered by your insurance can be confusing at best and infuriating at worst. In this article you’ll learn insurance terms and the most common ways physical therapy is covered.
Physical Therapists are Specialists
Why isn’t the copay for physical therapy the same as seeing my doctor? A Physical Therapist is considered a specialist by insurance companies in most states, including Idaho. Most insurance plans require patients to pay more to see a specialist. For example, your doctor visit may be a $25 co-pay and a specialist may be a $50 co-pay. Or, your insurance may require you to meet your deductible when seeing a specialist.
What Type of Insurance Coverage is Most Common for Physical Therapy?
Here are the three most common types of physical therapy coverage we see:
- Deductible, then co-insurance
- Co-pay only
- Deductible, then co-pay
1. Deductible, then co-insurance
What is a deductible? The deductible is the amount you pay out of pocket before your insurance will cover any portion of your physical therapy visits. Deductibles reset at the beginning of your benefit period.
After your deductible is met, your insurance begins to pay some of the costs. But they require you to pay a portion, called co-insurance.
What is co-insurance? The percentage of the visit you’re responsible for after meeting your deductible. For example, your insurance pays 80%, and you pay 20%. Your insurance plan determines the co-insurance percentage.
2. Co-pay only
What is a co-pay? A co-pay is a flat fee you pay for each visit. Your insurance plan determines the co-pay amount.
3. Deductible, then co-pay
Some plans require you to meet your deductible before you pay a co-pay for each visit.
Other Coverage Terms
Out of Pocket Maximum: The amount you pay out of pocket during your benefit period before your insurance will cover 100% of your medical care. This is usually a large amount (i.e. $10,000 or more). This resets each benefit period.
Benefit period: The 12 months that make up your benefit year, decided by your insurance plan. Most commonly, insurance plans have a benefit period of January 1 to December 31. This includes participants in the Idaho Health Exchange, or those who purchase individual coverage. Check with your employer or insurance plan to learn what your benefit period is.
Physical therapy limits: Most insurance plans have a limit on the number of physical therapy visits they’ll cover in a benefit period. For example, a common amount is 20 visits. With some insurance companies, that’s a hard limit. Other insurers will approve more visits if the provider makes a good case for medical necessity based on documentation.
Do I need a referral? Most states allow some form of direct access, meaning that you can go directly to a physical therapist without a referral from your doctor. Idaho allows full direct access. Regardless, some insurance companies require a referral before they’ll cover your visits. That means you don’t need a referral unless your insurance carrier requires it.
Do I have physical therapy coverage? There are very few insurance plans that do not cover physical therapy, although they do exist.
Check with your insurance company to learn the details of your plan. When you shop for a new insurance policy, consider how physical therapy will be covered.
Considerations When Shopping for Health Insurance
If your employer supplies your health insurance, you’ll have to choose from the provided options. If you’re in a position to choose, it’s important to note that the monthly bill you pay doesn’t tell the whole story. For example, a plan with a lower monthly premium typically comes with higher out of pocket costs (i.e. high deductible) when you use your benefits.
Weigh the benefits and risks. Do you want to pay less up front and have significant medical bills if something were to happen? Or, do you need the security of being covered no matter what happens? Obviously, it’s a complex decision to make depending on your life circumstances.
We hope you’ve learned something new about how your insurance plan might cover physical therapy. Interested in knowing how much physical therapy will cost? Click here to learn more.
Disclaimer
Almost every day, our patients are asking us — does insurance cover physical therapy?
This is a question that needs a closer look as there isn't one straightforward answer.
Physical therapy (PT) is imperative for various rehabilitation and recovery programs. It sometimes is necessary to help you recover from an injury, post-surgery, or help treat an existing condition.
One or two sessions will not suffice to achieve long-lasting results, so insurance coverage becomes vital when paying the fees and other expenses. No one should get in debt to recover from a health problem, as it should be a priority for any human being.
Let's explore the subject of PT insurance in detail.
Physical therapy health insurance coverage
So is physical therapy covered by insurance?
First, the good news - most insurance companies and their plans, whether governmental or private, cover medically necessary physical therapy services.
Physical therapy qualifies as an essential health benefit among other rehabilitation services under the Affordable Care Act. As HealthCare.gov explains, it's the health care services that meet medical standards and are needed to diagnose or treat an illness, injury, condition, or disease.
Usually, if the insurance company covers the PT insurance, it is around 50-75 percent of the cost. Don't forget that some insurers may ask their clients to provide a doctor's referral or care plan before they do so.
Most common health insurance for physical therapy
There are three most common types of physical therapy coverage that most insurers provide. Let's look at each one of them.
Deductible and coinsurance The deductible is the amount the patient pays out of pocket before the insurance covers any costs. After the deductible is met, the insurance begins to pay some of the costs. However, the patient still needs to cover a chunk, which is called coinsurance. Coinsurance is the percentage of the visit the client needs to pay after meeting their deductible. This percentage is determined by each company differently and individually.
Only co-pay The simplest option when the patient pays a flat fee determined by the insurer for each visit.
Deductible and co-pay The third option is when the patient meets the deductible and then co-pays for every visit.
Medicare coverage for physical therapy
Medicare is an insurance program covering people aged 65 years or older and younger people with disabilities and certain other conditions. It is provided by the federal government.
Medicare for physical therapy generally covers around $30 for each procedure and about & $100 for a PT session.
Medicare and physical therapy can get confusing, so here are the different Medicare plans and how each of them relates to PT coverage.
Medicare Part A It's also called hospital insurance and will cover the patient's treatment during his stay at rehabilitation or a nursing facility. It can also reimburse some home health care that a doctor deems medically necessary after a hospitalization.
Medicare Part B Covers essential outpatient services such as medically necessary physical therapy for patients. It includes diagnosing and treating chronic diseases and conditions that may require therapy and some preventative care.
Physical therapy Medicare cap for parts A and B is a total of $2,050.
Medicare Part C It is the insurance provided by private companies. It includes coverage offered in Medicare parts A & B and other services, including PT when medically necessary.
Medicare Part D Doesn't cover physical therapy treatments but pays for medications that are part of the recovery plan.
Medigap This is a supplemental insurance plan sold by private insurers. It doesn't cover PT but pays for any associated out-of-pocket costs such as co-pays, coinsurance, deductibles, and medical expenses outside the U.S.
Physical therapy cost without insurance
According to Theervo.com, the average physical therapy cost can range from $20 to $350 per session, with most paying $30 with insurance and $125 per session is the average physical therapy cost without insurance.
The PT fees include the initial consult and the use of any special equipment. The final cost will depend on the type of injury and treatment and the number of sessions received.
Are there some services that physical therapists provide that are not covered by insurance?
It's important to know that certain services will not be covered by insurance. These are usually various wellness, fitness programs, health education, prevention, and sports performance enhancements.
Most insurance plans will also cover only a limited number of physical therapy visits, and usually, it's 20 visits.
Check with your insurer to find out about your plan.
What if you don't have insurance?
Those who don't have health insurance covering physical therapy services will need to pay the provider directly.
To reduce the costs, the patient can ask for a modified program, fewer sessions, or discuss a special payment plan.
Do I have physical therapy coverage?
Most insurance plans cover physical therapy, but it's best to check with the provider to have the definitive answer.
And if you're looking for an insurance policy at the moment, make sure you check that in advance.
How to choose health insurance?
First of all, if the employer provides your health insurance, you will need to choose from their list.
If you're getting it on your own, you have more options. In any case, it's crucial to do your research as often a plan with a lower monthly premium comes with higher out of pocket costs.
Here are some questions you should ask:
Does insurance cover physical therapy?
Is my provider in-network or out-of-network?
Do I need to get a referral from my doctor before starting PT?
How many PT visits can I get covered?
Does my plan pay for PT in an inpatient or outpatient setting?
Does my current plan have any limits or exclusions for PT?
How much will I need to pay out-of-pocket?
Final Conclusion
Most insurance plans cover physical therapy. However, there are many variables to consider, such as deductibles, co-pays, coverage limits, and specific requirements to qualify.
So the best insurance for physical therapy is the one that works best for your circumstances and financial situation. Make sure you do your research and ask all the questions before you choose your insurance provider.
Physical Therapy in Miracle Rehabilitation and Physical Therapy Center
Miracle Physical Therapy and Massage Center Inc. provides physical therapy and massage therapy for diverse diagnoses.
Our physical therapists understand how important it is to maintain an active lifestyle and provides therapy plans and implementation for most medical situations, including sports injuries, traumas after car accidents, strokes, or other debilitating injuries.
Whether you've been injured on the field, are recovering from surgery, or simply twisted your back while gardening, we are dedicated to getting you back in the game of life. Let your insurance cover physical therapy and let's get you back on the right path.
Get in touch with Miracle Rehab to talk about your financial situation and whether you have health insurance or not. We will make sure to find the best outcome possible for you.